Q&A: A Yale Psychologist Calls for Radical Change in Therapy

(Updated) Is individual therapy overrated and outdated? In many ways, says Alan Kazdin, a professor of psychology and child psychiatry at Yale University, writing in the leading journal Perspectives on Psychological Science.

Kazdin contends that treatments for mental health issues have made great strides over the last few decades, but the problem is that these evidence-based therapies aren’t getting to the people who need them. Nearly 50% of the American population will suffer some kind of mental illness at least once in their lifetimes, but the mental health field, which relies largely on individual psychotherapy to deliver care, isn’t equipped to help the vast majority of patients. Some 70% currently go untreated.

Healthland spoke with Kazdin about his views and recommendations for change. (Note: we have updated this piece at Kazdin’s request to include additional information on his perspective. Healthland will also continue its coverage of the controversial issues raised here.)

Q:Why did you decide to speak out about this issue?

A: For me, it’s like an emperor’s new clothes situation. All these people — including me — do very expensive controlled trials of therapy and yet we see that most people aren’t getting treatment at all. Something is wildly, drastically wrong.

In Manhattan, which has no shortage of therapists, I’ve asked for referrals for evidence-based treatments like cognitive behavioral therapy and several times had high-level professionals be unable to provide one.

Totally! [It is hard to get] evidence-based treatments. Among the many reasons is that scientific innovation in any field normally takes a decade or two to filter down to the public. It’s somewhat sad, but normal.

Many therapists say they want to be “eclectic,” rather than trying any new treatment system that has been proven to work.

That’s a red herring: I individually tailor treatment specifically for you. The research shows that no one knows how to do that. [And they don’t know how to monitor your progress.] Think about if you went to your physician and had a blood test, but they never read the results. They don’t have any idea if you’re getting better. It’s ridiculous.

So why aren’t patients clamoring for better therapy?

This is a very sad commentary for me. When I was starting out, I thought that the public would be an ally, but research shows that satisfaction with therapy is not very much related to getting better. [So, they don’t necessarily realize they are not getting good treatment.]

The first thing we need is the commitment of professionals to really help people. We need very different ways of giving treatment. Many of them are out there already. For example, there are online treatments. There’s self-help that could reach millions of people in need, if we did things other than one-to-one New Yorker cartoon psychotherapy. We should have more guidelines [about what to do therapeutically] — that would offend the profession, but benefit the public.

I’m proselytizing only because someone has to look at this inertia. Right now in time zones all over country, someone is getting evidence-based treatment but there are eight or nine other people who aren’t getting anything.

Any quarrel is not with psychotherapy and its effects. Yet, individual psychotherapy is the dominant mode of delivering psychological treatment and just cannot reach most people in need.

But if you don’t rely on therapy for professional guidance, there’s lots of self-help that is ineffective or even harmful.

Here’s what’s really hard. The self-help literature has a pile of evidence-based treatments that are well-studied in randomized controlled trials. But the poor public has no chance. You go to the bookstore or look online, and 99% of what you get is someone winging it. Those are not usually evidence based.

The profession should be out there taking the moral high ground [and providing appropriate guidance].

There are a couple of online cognitive behavioral treatments for clinical depression that have been shown to work in randomized controlled trials. The profession should be proselytizing, telling people that there’s online treatment that’s free or inexpensive, and if that doesn’t help, then maybe you should see a therapist.

But what about the studies suggesting that it’s the relationship between the therapist and the client — not the technique — that matters?

There’s no real evidence for this. Yes, a good relationship is related to clinical outcome but it plays no causal role whatsoever. Some new therapies don’t require a relationship at all. For example, there’s essay-writing therapy for trauma. It’s a set of self-administered treatments, there’s no relationship there — it’s not even an essential condition.

It’s way overplayed. We did a study showing that the relationship isn’t so special. The quality of the relationship [between therapist and patient] relates to how social the patient was before treatment. It may be correlated to effectiveness of treatment, but the relationship has not shown to be causally involved.

If you want to get over an anxiety disorder, do graduated exposure. But sit down and relate to me or love me like your mom and dad? There’s no evidence for that.

Social support is needed. The feeling of isolation is related to immune system [dysfunction] and early death. Sometimes, that’s all therapy is. There was a 1986 book called Psychotherapy: The Purchase of Friendship. So, what am I coming for? It might well just be to chat; that’s beautiful, but don’t come for anxiety or depression.

How about to mobilize people’s own support systems?

That’s not what therapists are talking about. It’s me, my wonderful relationship to you is going to change your whole life? It’s way outdated.

Is there a role for individual therapy? What is its proper place?

Individual therapy has three important roles. First, many variations have been effective in treating debilitating psychological problems — for example, depression — and hence, is a viable tool to help. Second and related, many crises of life — death of a loved one, divorce, stress — can be helped by temporary aid or by providing coping techniques. Psychotherapy can help with these situations too. Third, from therapies we know to work, perhaps we extract their essence and provide that in novel ways to reach many people.

Right now, therapy is often the first resort or the only resort of receiving needed psychological services. My view is that it ought to be only one way of providing treatment and perhaps late in the game, if more easily disseminable interventions have not worked. This is analogous to holding off on back surgery until we know that much more user-friendly and widely spread interventions — for example, exercise, programmed activities — are not working.

What are some types of individual therapy that are supported by evidence?

There are now many forms of individual therapy with strong evidence. Two prominent examples for adults are graduated exposure for the treatment of anxiety, and cognitive therapy for the treatment of depression. There are Internet and self-administered versions of these that also are effective.

Two prominent examples for children are behavior analysis for children with autism spectrum disorders, and parent management training for the treatment of children with severe aggressive and antisocial behavior. These and other evidence-based treatments can help a variety of clinical disorders.

So, who’sgoing to help people find treatment? A general practitioner?

It’s unrealistic to ask GPs to do it. It might be handled by professional authorities, or government could help people find the appropriate consortium of online services. You could have some sort of decision tree. Right now, we’re missing most people who need care. There could be an app for this.

And how do you let people know about the help that could be available?

That itself needs a portfolio of communications. There could be pamphlets and brochures available when you go to the doctor’s office. In [Scandinavian countries,] when they want to get rid of bullying, they do things like put information on milk cartons. But that’s a marketing, communications, business school issue. It’s a challenge for psychology, but we also really need to get collaborators involved and bring in the expertise of other fields to make it happen.

What do you think people can do to help change the mental health system?

We should unite in some way to try to bring together a critical mass of people who would have a voice to educate the public and serve at least as triage.

Won’t psychologists see this as a threat to their livelihood?

They’re already not doing too well. And if professional and public priorities come into conflict, the only way to go is to [favor] the public, to take the moral high ground. People are genuinely suffering.